tag:blogger.com,1999:blog-26666124.post3428093904585704047..comments2015-03-03T11:57:53.323-05:00Comments on Shrink Rap: What Makes for Better Care: Capitation or Fee-For-Service?Dinahnoreply@blogger.comBlogger59125tag:blogger.com,1999:blog-26666124.post-87867361338474615082012-10-05T18:55:18.337-04:002012-10-05T18:55:18.337-04:00Hi Tigermom, you must be a very compassionate ther...Hi Tigermom, you must be a very compassionate therapist to do 45 minutes with each client. Thank you for your explanation. Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-1782456315072115662012-10-05T12:43:58.410-04:002012-10-05T12:43:58.410-04:00Alison: “This is the pernicious aspect of being pa...Alison: “This is the pernicious aspect of being paid for goods and services: conflict of interest.”<br /><br />Rob: “This is backwards. Where a service is free or nearly free, there is no disincentive for me, the seller, to sell as much of my services as possible.”<br /><br />You’re changing the subject again. I’m talking about the seller getting paid; you’re talking about the buyer paying. These are different aspects of the transaction and can be separated. For instance, you could be paid a lot of money by public insurance to which I contribute little or nothing. Alternatively, you could be receiving a salary for some aspect of my care while I am in hospital and paying out of my pocket and through the nose.Alison Cumminshttp://www.blogger.com/profile/06370841996857073237noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-79536968803859042802012-10-05T12:35:31.747-04:002012-10-05T12:35:31.747-04:00Rob: “If you think over-treatment is bad in medici...Rob: “If you think over-treatment is bad in medicine, it is absolutely B**-S*** crazy in dentistry.” Yep. And it’s pretty much completely free enterprise. So it’s hard to see how more free enterprise would fix overtreatment in other disciplines. <br /><br />Rob: “People defer to doctors and dentists too much. That&#39;s understandable, if misguided.” Can you be more explicit about the misguided bit? I’ve never had my teeth capped. I’ve only ever seen one person with multiple myeloma, and based on this anecdote I will refuse treatment for it if I ever develop it. I’m really not sure how I’m supposed to not defer to doctors and dentists if I need care for something I’ve never had before.<br /><br />From reading blogs, one of the things medical personnel apparently hate the most in the world is resucitating someone who is dying. The person is demented and very ill. They go into heart failure. While the medical team leaps into action, a doctor discusses alternatives with the family. Tearfully they say, “Do everything!” Feeling terrible about it, the medical team do everything. Unless the family are allowed to actually watch the medical team breaking granny’s ribs and shoving tubes into her, in which case they tell the team to stop. <br /><br />So. You are the doctor and you have carefully explained the risks and benefits of attempting to resucitate my dear one and I make a decision. When I actually see you in action, I make a different decision. It seems that your experience of providing medical care gives you a deeper understanding than you can convey by simply listing risks and benefits. *What is so misguided about deferring to someone who knows what they are talking about?* How exactly would discussing a bill to be paid out-of-pocket make this conversation more productive?<br /><br /><br />Rob: “If people had to pay for the services they receive, they would buy much more judiciously.” As we are both aware, this doesn’t seem to be the case in dentistry. There’s an asymmetry of information problem, a little bit like you don’t know if a particular watch or necklace or whatever is better than that one, you only know it costs more, so you use that as a proxy for “better” and you choose the more expensive one, hoping to get better value. Even though it may not actually be better.<br /><br />Rob: “If people had to pay for the services they receive ... doctors would be compelled to speak honestly about benefits and harms.” I don’t understand how this follows at all. There is a massive leap in logic here and you’ll need to walk me through it. “If people had to pay for their own used cars, used car sales staff would be compelled to speak honestly about the features and defects of the cars they are selling.” I don’t see how it follows. Alison Cumminshttp://www.blogger.com/profile/06370841996857073237noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-36864254930196453302012-10-05T12:07:38.003-04:002012-10-05T12:07:38.003-04:00&quot;...[T]his is the pernicious aspect of being ...&quot;...[T]his is the pernicious aspect of being paid for goods and services: conflict of interest&quot;<br /><br />This is backwards. Where a service is free or nearly free, there is no disincentive for me, the seller, to sell as much of my services as possible. This is a serious conflict of interest. I fight the impulse every day.<br /><br />If, however, families had to pay for the services I provide, the disincentive to over-charge and over-sell would obviate my need to fight the impulse to over-treat.<br /><br />The crux of the problem with capitation, to return to Dinah&#39;s original post, is that the burden of making economic decisions falls to the wrong party, namely the seller.<br /><br />Regarding my dental colleagues:<br /><br />If you think over-treatment is bad in medicine, it is absolutely B**-S*** <i>crazy</i> in dentistry.<br /><br />People defer to doctors and dentists too much. That&#39;s understandable, if misguided. If people had to pay for the services they receive, they would buy much more judiciously, AND doctors would be compelled to speak honestly about benefits and harms. rob lindemanhttp://natickpediatrics.netnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-78410023683756614022012-10-05T10:59:05.476-04:002012-10-05T10:59:05.476-04:00Rob: “the families in my practice buy a TON of ser...Rob: “the families in my practice buy a TON of services that they would probably not buy if they were actually paying for them.” <br /><br />Yes, this is the pernicious aspect of being paid for goods and services: conflict of interest. I see it when I compare my attitude towards medical care (covered by public insurance) with dental care (covered by a mix of private insurance and cash). <br /><br />I don’t pay directly for my medical care. If a doctor thinks I need a service that is covered by public insurance, I believe them. There are waits for these services, and quotas. The doctor is much more aware of the constraints on the system than I am and has judged that I should get the service. So I do. I trust that the doctor isn’t loading me up with extra tests or interventions. If the doctor tells me I need it, then I must really need it.<br /><br />(I am completely aware of the pernicious aspects of quotas! Not arguing <i>for</i> them, just reviewing the social effects of a sense of stewardship of a limited resource. I am not arguing for any particular way limits should come into being!) <br /><br />When I go to the dentist, I am perfectly aware that the guy I see loves dentistry, loves gadgets and technology, wants to share what he loves and has lots of bills to pay. If he recommends something, it may or may not be the best choice for me but I don’t necessarily have the expertise to make that judgement. So if my insurance covers it, I get it. Because I pay for my insurance I feel entitled to get all the goodies it covers; I don’t worry about stewardship. Alternatively, if it’s not covered by insurance I don’t have a good way of evaluating whether I really should buy what he’s selling. He urged a friend of mine to get four teeth capped instead of the two that actually needed capping so that they would all be the same colour. He insisted that she would be unhappy if she only got the two done. Well, she was paying out of pocket and only got the two. I can’t see the difference. She looks fine. She’s satisfied. If it had been me, I’d probably have given in and gotten the extra caps I didn’t need, and given up other things I value more than an imperceptible difference in tooth colour. So far I haven’t been placed in that position — everything he sells me is covered by private insurance, so I have always bought it — but as I age and wear out it’s only a matter of time.<br /><br />(Clearly I still see this guy. The fact that dentistry is not covered by public insurance does not cause me to boycott dentists.)Alison Cumminshttp://www.blogger.com/profile/06370841996857073237noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-17869775673666568622012-10-05T10:38:24.550-04:002012-10-05T10:38:24.550-04:00Rob: “People value what the pay for and pay for wh...Rob: “People value what the pay for and pay for what they value. I wonder how valuable my general Pediatric services are to parents who do not pay, or pay very little, to see me.”<br /><br />You’re right, you don’t say “only.” There are different ways of reading that statement. <br /><br />1) “People value what they pay for...” I may value something less if I pay for it. I’m not normal, but I exist. This is also what people say when they’re claiming that people abandon their pets because they are too inexpensive and that the problem of abandoned pets would disappear if everyone bought high-priced animals from breeders. I dispute this assertion.<br /><br />2) “... and pay for what they value.” Sometimes. Sometimes they can’t pay even when they value something very much. Sometimes they prefer to steal even when they can pay. Sometimes they prefer it to be a gift. (Sexual contact and comfort is something many people value very highly, but it’s common to refuse to pay for it.)<br /><br />3) “I wonder how valuable my general Pediatric services are to parents who do not pay, or pay very little, to see me.” Perhaps you are simply saying that money is the only way you personally have of measuring your value to others? You would need to not only charge a fee, but also look at their tax returns, which would be very intrusive. A person who doesn’t pay for orthopedic surgery for their child doesn’t necessarily not value the care to their child, they may be unable to pay. Someone else might enjoy flashing their money around and buying lots of goods and services to impress other people, not because they value the goods and services. You would have to charge an awful lot of money to those people to determine that they actually valued what you were charging for. <br /><br />I actually have some sympathy for your statement, “the families in my practice buy a TON of services that they would probably not buy if they were actually paying for them.” More next.Alison Cumminshttp://www.blogger.com/profile/06370841996857073237noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-35103180834509714462012-10-05T09:35:21.105-04:002012-10-05T09:35:21.105-04:00Read the posts. The word ONLY never appears. One...Read the posts. The word ONLY never appears. One sees what one wants to see, right Dinah?rob lindemanhttp://natickpediatrics.netnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-65720646005584555302012-10-05T08:26:11.264-04:002012-10-05T08:26:11.264-04:00oops! Sorry for the wonky grammar, I didn&#39;t r...oops! Sorry for the wonky grammar, I didn&#39;t review my post carefully enough!Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-62482904374001636142012-10-05T08:24:02.211-04:002012-10-05T08:24:02.211-04:00Hi, I&#39;m the anonymous who asked about charging...Hi, I&#39;m the anonymous who asked about charging for psychiatry/psychotherapy. I would expect psychiatrists to charge more for things that require specialist medical training, but it wouldn&#39;t seem cost efficient to be charged. I work for the NHS in the UK as a psychotherapist in a multi-disciplinary child and adolescent team, but I trained first as a clinical psychologist. Our psychiatrists are the top of the pay scale and they do things that require their expertise - medication, oversee physical assessment and monitoring, high risk assessment, specialist diagnosis, and case consultation. In my team, at least, they don&#39;t do therapy or routine diagnosis which can be done by other skilled professionals. If something is outside of our expertise, then we consult, and they may see the patient themselves. And then they hand them back to their colleagues. It is one of the reasons I like working in the NHS, it means I can safely work with higher risk cases than I would feel comfortable with as a single practitioner and it means care is coordinated and best practice can be followed (e.g., rarely do young people get meds without psychological therapy). In order for us to successfully treat as many people as possible within our budget we have to reserve the psychiatrists for cases that require their expertise.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-84711563963231182262012-10-04T23:11:36.947-04:002012-10-04T23:11:36.947-04:00Hi Anonymous whose doctor charges $140 for a med c...Hi Anonymous whose doctor charges $140 for a med check and $180 for a therapy hour.<br /><br />I wanted to tell you why the time is not proportionally charged. It takes more work to look after someone who comes in for med checks than for someone who comes in, usually, more frequently for psychotherapy and medication for a longer session.<br /><br />The longer the time between appointments, the more likely the patient will reschedule, run out of their medication between appointments, have questions arise that they want discussed quickly over the phone. All this easily amounts to the work involved for one or two additional sessions.<br /><br />Think of the steps: take the phone message, pull the chart, review the chart, return the call, play a little phone tag, talk to the patient, make a plan, call in a script - which alone takes 15 minutes typically, and document it all so you remember what you did at the next appointment, and you probably should charge more for the shorter less frequent appointment now that I think about it.<br /><br />Some doctors do charge exactly proportionally based on time spent in the office with the patient, but it is less common in my neck of the woods.<br /><br />I actually have transitioned over the last 2-3 years to seeing almost everyone for 45 minutes. It simplifies everything except my schedule. Now I book up more quickly but I am happier with my patient relationships and outcomes.Tigermomhttp://www.blogger.com/profile/15525962425980447155noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-46187958352129725912012-10-04T22:32:13.766-04:002012-10-04T22:32:13.766-04:00Anonymous who is not talking about Gunter,
Exampl...Anonymous who is not talking about Gunter,<br /><br />Examples?Alison Cumminshttp://www.blogger.com/profile/06370841996857073237noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-11206915676610854972012-10-04T22:29:36.475-04:002012-10-04T22:29:36.475-04:00Oh Rob, you do like changing the subject.
You sta...Oh Rob, you do like changing the subject.<br /><br />You stated that people only value what they have paid for. I dispute this statement and find it personally offensive. I offer counterexamples, including some that relate to healthcare. Alison Cumminshttp://www.blogger.com/profile/06370841996857073237noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-74623710307923541002012-10-04T22:17:55.765-04:002012-10-04T22:17:55.765-04:00Nope, i&#39;m not talking about Gunter. i&#39;m t...Nope, i&#39;m not talking about Gunter. i&#39;m talking about people on here who criticize a system they know nothing about.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-36022964301977257122012-10-04T22:09:46.937-04:002012-10-04T22:09:46.937-04:00Anonymous,
Are you saying that you don&#39;t place...Anonymous,<br />Are you saying that you don&#39;t place much stock in the opinions of Dr Jen Gunter, who works in the US?Alison Cumminshttp://www.blogger.com/profile/06370841996857073237noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-37051784950703872152012-10-04T21:47:09.073-04:002012-10-04T21:47:09.073-04:00Alison, I don&#39;t place much stock in the opinio...Alison, I don&#39;t place much stock in the opinions of our health care system when it comes from those who haven&#39;t experienced it as a patient nor worked in the U.S. health care system, because you there&#39;s a whole lot you don&#39;t know. <br /><br />I have been a patient in the U.S. health care system, I&#39;ve worked in the U.S. health care system, and I have worked on multiple clinical trials involving other countries. I&#39;ve even worked with Canadians in U.S. hospitals who have a much more balanced view of our health care system - both the good and bad, and their opinion does mean something because they actually do know what goes on here.<br /><br />Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-44640747256105388972012-10-04T20:19:54.620-04:002012-10-04T20:19:54.620-04:00Last anon - because med checks are expected to be ...Last anon - because med checks are expected to be less frequent while psychotherapy is expected to be more frequent and consistent. Mine charges $350 for either, but doesn&#39;t do pure medication maintenance. His minimum is 1 x month, and that session is 45 minutes like any other. Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-86970369612510709572012-10-04T19:26:36.793-04:002012-10-04T19:26:36.793-04:00Mine charges $140.00 for a 20 minute med check, bu...Mine charges $140.00 for a 20 minute med check, but charges $180.00 for a 50 minute session for psychotherapy. Go figure!Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-74143249964854711862012-10-04T17:36:15.829-04:002012-10-04T17:36:15.829-04:00I&#39;m curious if psychiatrists who do psychother...I&#39;m curious if psychiatrists who do psychotherapy charge the same rate for psychotherapy as they do for psychiatric services?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-90712747526089690542012-10-04T12:53:16.993-04:002012-10-04T12:53:16.993-04:00I have phenomenol insurance... employment through ...I have phenomenol insurance... employment through a government agency - group plan. I pay just $10 per office visit, no deductible and no limit on office visits. This is not the norm I realize, and I also took the job and a munch, much lower salary, because the benefits were so good. I feel very fortunate. There is something to say about coverage. There have been times that I have paid COBRA and some crazy premiums, but it was worth it to me. I have seen many family and friends that have become buried deep in medical debt, or it bankrupt them.<br /><br />On a side note, it&#39;s Mental Illness/ health Awareness Week!Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-59772913561796908692012-10-04T12:24:54.407-04:002012-10-04T12:24:54.407-04:00I have a PPO with a $15 copay and $500 deductible....I have a PPO with a $15 copay and $500 deductible. For general mental health counselling there is a limit of 24 sessions in a year. However, if your mental illness is considered &quot;biological&quot; like bipolar or schizophrenia then then there is no limit to appointments. I am bipolar and was tapered off my meds last fall to try to get pregnant. I did well for about 6 months but then crashed into the worst depression of my life. My shrink (an awesome guy) basically negotiated with me that he wouldn&#39;t put me in the hospital if I agreed to see him daily until I was stable again. That helped me immeasurably and I saw him daily for 6 weeks. If my insurance had run out and not covered my appointments then I probably wouldn&#39;t be here today. SarahJaynenoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-69631113734542416422012-10-04T12:22:21.949-04:002012-10-04T12:22:21.949-04:00The ideological battle between Statism/Collectivis...The ideological battle between Statism/Collectivism and Freedom/Libertarianism is old and probably won&#39;t be resolved in the comments section of Shrink Rap, but wouldn&#39;t it be really cool if it were?<br /><br />Suffice it to say that Statism/Collectivism has had its day, and has proven to be a recipe for a solitary, poor, nasty, brutish, and short life for the poor individual. <br /><br />Although I follow Jen Gunther and respect her highly, I would commend the works of Ludwig von Mises to readers of Shrink Rap. I&#39;m inclined to recommend by John Locke, but unless you&#39;re a 17th century Scotsman it&#39;s rough reading. <br /><br />I&#39;ve read The Communist Manifesto and almost died half-way through Das Kapital. I&#39;d say von Mises and Locke get it right and Marx got it wrong. But we may disagree.rob lindemanhttp://natickpediatrics.netnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-62784915562480030832012-10-04T10:31:21.059-04:002012-10-04T10:31:21.059-04:00For Rob who thinks that the only reason a human be...For Rob who thinks that the only reason a human being will value anything is if they have paid cash for it, and that if we think he means kids we’re being absurd.<br /><br />Exactly. Your point that human beings value things for many other reasons than having paid cash for them is well-taken.<br /><br />You think the children analogy is far-fetched, but I have heard exactly that sentiment expressed with regard to pets. Breeders of expensive animals state that the reason for the high rate of pet abandonment where I live in Montreal is that people get their pets from the neighbour whose dog had a litter, or they adopt a feral kitten from the alley in the fall. Because the animals were free or low-cost, they do not value them and abandon them easily. As a pet owner, I can tell you that logic is as absurd to me as the same logic applied to children is to a parent.<br /><br />To a certain extent, I might value things less if I pay for them. The money removes any social aspect of the exchange. I paid for it, therefore I have the right to do anything I want with it, including throw it away. I paid for it, and if what I got wasn’t to my taste then I complain. <br /><br />If the society as a whole has collaborated to make something available to me to enhance my ability to participate in and contribute to society, like education or health care, then it’s not just about my personal taste. It’s about social engagement. If my doctor expresses concern about me, it’s not because I’m paying her to, it’s because I am a valuable human being. <br /><br />I valued my mother’s advice, but not because I paid for it.Alison Cumminshttp://www.blogger.com/profile/06370841996857073237noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-65727244071459926832012-10-04T09:49:27.451-04:002012-10-04T09:49:27.451-04:00For Anonymous who thinks that Canadians shouldn’t ...For Anonymous who thinks that Canadians shouldn’t express horror at the American health care payment mess even though we know about it because of all the Americans express horror at it.<br /><br />Jen Gunter MD is a Canadian trained in Canada, practicing in the US, so she would know. And this is what she says.<br /><br />http://drjengunter.wordpress.com/2012/08/27/the-one-horror-story-thats-missing-when-canadians-talk-about-health-care/<br /><br />(Parenthetically, she thinks that the medical board exams in her specialty in the US are much easier than those in Canada — much too easy. http://drjengunter.wordpress.com/2012/07/05/why-i-disagree-with-the-ama-over-the-need-for-physicians-to-be-board-certified/ )Alison Cumminshttp://www.blogger.com/profile/06370841996857073237noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-17867590336542820232012-10-04T04:36:15.544-04:002012-10-04T04:36:15.544-04:00Let&#39;s reverse that: what percentage of drugs d...Let&#39;s reverse that: what percentage of drugs do Americans take that were created by European companies? Have you checked out how many of your drugs are from Europe versus America lately?<br /><br />Yet you still pay buttloads more than those in the country it was created in, where it was created makes no difference. While America spits out drugs left and right, you still pay more for your drugs than necessary, and other countries paying more for their drugs wouldn&#39;t lower the cost of your drugs, it would simply increase the profits that Big Pharma rings in. So, despite all your strides in research, how exactly are you benefiting aside from drugs that everyone else gets to pay less for? Oh that&#39;s right, we don&#39;t question Big Pharma, they&#39;re our saving grace, we point the fingers at everyone and everything else.<br /><br />Where the drug was made has nothing to do with the price that you pay. And none of it would be possible without the research that lead to the discovery that made it possible for drugs to target the illness - research that Canada is a part of. Canada may not be a leader when it comes to drug production, but we&#39;re as innovative as the next and the research we spit out has made it possible for your drug companies to make the drugs they profit from.<br /><br />Should Canada try to develop more drugs themselves? Of course, always. (aside: some of those companies outside of Canada have labs developing drugs within Canada. The country may hail from Europe, or the USA, but that doesn&#39;t necessarily mean the drug was invented there)<br /><br />You&#39;re still ignoring the fact that pharmaceutical companies, in and outside the USA, are ripping your country off. Because you make it possible. You don&#39;t need to let the company rip you off in the name of drug research, Europe is a prime example of that.<br /><br /><br />Having said all that, while I may criticize the US healthcare system, I also heavily criticize my own. I believe that being honest about the flaws in our system will help to improve the system in the long run. R&amp;D is the least of our issues:<br /><br />1. Surgical wait times<br />2. Family doctor shortage<br />3. Quebec is a mess<br />4. Eyecare coverage<br /><br />So don&#39;t think that I&#39;m criticizing the USA any differently than I would criticize my own country&#39;s healthcare system, or any other country&#39;s healthcare system for that matter. Likewise, you&#39;re just as free to criticize Canada as you see fit, it certainly doesn&#39;t do our system any harm to receive reality checks from outside sources.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-81833044971884748482012-10-04T03:08:07.455-04:002012-10-04T03:08:07.455-04:00What percentage of drugs Canadians take were creat...What percentage of drugs Canadians take were created in Canada? <br /><br />Doesn&#39;t make a lot of sense for Canadians to come onto U.S. websites and trash the U.S. health care system, if they&#39;ve never experienced U.S. healthcare nor worked in the U.S. healthcare system, but enjoy benefitting from it. It would be like me hanging out on Canadian health care websites and smugly telling them all that&#39;s wrong with their health care system even though I haven&#39;t been treated or worked in it. It doesn&#39;t make much sense. Anonymousnoreply@blogger.com